305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/12-4.32)

Sec. 12-4.32. (Repealed).

(Source: P.A. 90-9, eff. 7-1-97. Repealed by P.A. 90-564, eff. 12-22-97.)

(305 ILCS 5/12-4.33)

Sec. 12-4.33. Welfare reform research and accountability.

(a) The Illinois Department shall collect and report upon all data in connection with federally funded or assisted welfare programs as federal law may require, including, but not limited to, Section 411 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 and its implementing regulations and any amendments thereto as may from time to time be enacted.

(b) In addition to and on the same schedule as the data collection required by federal law and subsection (a), the Department shall collect and report on further information with respect to the Temporary Assistance for Needy Families ("TANF") program, as follows:

(1) With respect to denials of applications for benefits, all of the same information about the family required under the federal law, plus the specific reason or reasons for denial of the application.

(2) With respect to all terminations of benefits, all of the same information as required under the federal law, plus the specific reason or reasons for the termination.

(c) The Department shall collect all of the same data as set forth in subsections (a) and (b), and report it on the same schedule, with respect to all cash assistance benefits provided to families that are not funded from the TANF program federal block grant or are not otherwise required to be included in the data collection and reporting in subsections (a) and (b).

(d) Whether or not reports under this Section must be submitted to the federal government, they shall be considered public and they shall be promptly made available to the public at the end of each fiscal year, free of charge upon request. The data underlying the reports shall be made available to academic institutions and public policy organizations involved in the study of welfare issues or programs and redacted to conform with applicable privacy laws. The cost shall be no more than that incurred by the Department in assembling and delivering the data.

(e) (Blank).

(f) (Blank).

(Source: P.A. 95-322, eff. 1-1-08.)

(305 ILCS 5/12-4.34)

Sec. 12-4.34. Services to noncitizens.

(a) Subject to specific appropriation for this purpose and notwithstanding Sections 1-11 and 3-1 of this Code, the Department of Human Services is authorized to provide services to legal immigrants, including but not limited to naturalization and nutrition services and financial assistance. The nature of these services, payment levels, and eligibility conditions shall be determined by rule.

(b) The Illinois Department is authorized to lower the payment levels established under this subsection or take such other actions during the fiscal year as are necessary to ensure that payments under this subsection do not exceed the amounts appropriated for this purpose. These changes may be accomplished by emergency rule under Section 5-45 of the Illinois Administrative Procedure Act, except that the limitation on the number of emergency rules that may be adopted in a 24-month period shall not apply.

(Source: P.A. 91-24, eff. 7-1-99; 91-712, eff. 7-1-00; 92-10, eff. 6-11-01; 92-597, eff. 6-28-02.)

(305 ILCS 5/12-4.35)

Sec. 12-4.35. Medical services for certain noncitizens.

(a) Notwithstanding Section 1-11 of this Code or Section 20(a) of the Children's Health Insurance Program Act, the Department of Healthcare and Family Services may provide medical services to noncitizens who have not yet attained 19 years of age and who are not eligible for medical assistance under Article V of this Code or under the Children's Health Insurance Program created by the Children's Health Insurance Program Act due to their not meeting the otherwise applicable provisions of Section 1-11 of this Code or Section 20(a) of the Children's Health Insurance Program Act. The medical services available, standards for eligibility, and other conditions of participation under this Section shall be established by rule by the Department; however, any such rule shall be at least as restrictive as the rules for medical assistance under Article V of this Code or the Children's Health Insurance Program created by the Children's Health Insurance Program Act.

(a-5) Notwithstanding Section 1-11 of this Code, the Department of Healthcare and Family Services may provide medical assistance in accordance with Article V of this Code to noncitizens over the age of 65 years of age who are not eligible for medical assistance under Article V of this Code due to their not meeting the otherwise applicable provisions of Section 1-11 of this Code, whose income is at or below 100% of the federal poverty level after deducting the costs of medical or other remedial care, and who would otherwise meet the eligibility requirements in Section 5-2 of this Code. The medical services available, standards for eligibility, and other conditions of participation under this Section shall be established by rule by the Department; however, any such rule shall be at least as restrictive as the rules for medical assistance under Article V of this Code.

(a-6) By May 30, 2022, notwithstanding Section 1-11 of this Code, the Department of Healthcare and Family Services may provide medical services to noncitizens 55 years of age through 64 years of age who (i) are not eligible for medical assistance under Article V of this Code due to their not meeting the otherwise applicable provisions of Section 1-11 of this Code and (ii) have income at or below 133% of the federal poverty level plus 5% for the applicable family size as determined under applicable federal law and regulations. Persons eligible for medical services under Public Act 102-16 shall receive benefits identical to the benefits provided under the Health Benefits Service Package as that term is defined in subsection (m) of Section 5-1.1 of this Code.

(a-7) By July 1, 2022, notwithstanding Section 1-11 of this Code, the Department of Healthcare and Family Services may provide medical services to noncitizens 42 years of age through 54 years of age who (i) are not eligible for medical assistance under Article V of this Code due to their not meeting the otherwise applicable provisions of Section 1-11 of this Code and (ii) have income at or below 133% of the federal poverty level plus 5% for the applicable family size as determined under applicable federal law and regulations. The medical services available, standards for eligibility, and other conditions of participation under this Section shall be established by rule by the Department; however, any such rule shall be at least as restrictive as the rules for medical assistance under Article V of this Code. In order to provide for the timely and expeditious implementation of this subsection, the Department may adopt rules necessary to establish and implement this subsection through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the General Assembly finds that the adoption of rules to implement this subsection is deemed necessary for the public interest, safety, and welfare.

(a-10) Notwithstanding the provisions of Section 1-11, the Department shall cover immunosuppressive drugs and related services associated with post-kidney transplant management, excluding long-term care costs, for noncitizens who: (i) are not eligible for comprehensive medical benefits; (ii) meet the residency requirements of Section 5-3; and (iii) would meet the financial eligibility requirements of Section 5-2.

(b) The Department is authorized to take any action that would not otherwise be prohibited by applicable law, including, without limitation, cessation or limitation of enrollment, reduction of available medical services, and changing standards for eligibility, that is deemed necessary by the Department during a State fiscal year to assure that payments under this Section do not exceed available funds.

(c) (Blank).

(d) (Blank).

(e) In order to provide for the expeditious and effective ongoing implementation of this Section, the Department may adopt rules through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the limitation on the number of emergency rules that may be adopted in a 24-month period shall not apply. For purposes of the Illinois Administrative Procedure Act, the General Assembly finds that the adoption of rules to implement this Section is deemed necessary for the public interest, safety, and welfare. This subsection (e) is inoperative on and after July 1, 2025.

(Source: P.A. 102-16, eff. 6-17-21; 102-43, Article 25, Section 25-15, eff. 7-6-21; 102-43, Article 45, Section 45-5, eff. 7-6-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, eff. 6-16-23.)

(305 ILCS 5/12-4.36)

Sec. 12-4.36. (Repealed).

(Source: P.A. 95-622, eff. 9-17-07. Repealed by P.A. 97-689, eff. 6-14-12.)

(305 ILCS 5/12-4.37)

Sec. 12-4.37. Children's Healthcare Partnership Pilot Program.

(a) The Department of Healthcare and Family Services, in cooperation with the Department of Human Services, shall establish a Children's Healthcare Partnership Pilot Program in Sangamon County to fund the provision of various health care services by a single provider, or a group of providers that have entered into an agreement for that purpose, at a single location in the county. Services covered under the pilot program shall include, but need not be limited to, family practice, pediatric, nursing (including advanced practice registered nursing), psychiatric, dental, and vision services. The Departments shall fund the provision of all services provided under the pilot program using a rate structure that is cost-based. To be selected by the Departments as the provider of health care services under the pilot program, a provider or group of providers must serve a disproportionate share of low-income or indigent patients, including recipients of medical assistance under Article V of this Code. The Departments shall adopt rules as necessary to implement this Section.

(b) Implementation of this Section is contingent on federal approval. The Department of Healthcare and Family Services shall take appropriate action by January 1, 2010 to seek federal approval.

(c) This Section is inoperative if the provider of health care services under the pilot program receives designation as a Federally Qualified Health Center (FQHC) or FQHC Look-Alike.

(Source: P.A. 100-513, eff. 1-1-18.)

(305 ILCS 5/12-4.38)

Sec. 12-4.38. Special FamilyCare provisions. The Department of Healthcare and Family Services may submit to the Comptroller, and the Comptroller is authorized to pay, on behalf of persons enrolled in the FamilyCare Program, claims for services rendered to an enrollee during the period beginning October 1, 2007, and ending on the effective date of any rules adopted to implement the provisions of this amendatory Act of the 96th General Assembly. The authorization for payment of claims applies only to bona fide claims for payment for services rendered. Any claim for payment which is authorized pursuant to the provisions of this amendatory Act of the 96th General Assembly must adhere to all other applicable rules, regulations, and requirements.

(Source: P.A. 96-20, eff. 6-30-09; 97-689, eff. 6-14-12.)

(305 ILCS 5/12-4.39)

Sec. 12-4.39. Dental clinic grant program.

(a) Grant program. On and after July 1, 2012, and subject to funding availability, the Department of Healthcare and Family Services may administer a grant program. The purpose of this grant program shall be to build the public infrastructure for dental care and to make grants to local health departments, federally qualified health clinics (FQHCs), and rural health clinics (RHCs) for development of comprehensive dental clinics for dental care services. The primary purpose of these new dental clinics will be to increase dental access for low-income and Department of Healthcare and Family Services clients who have no dental arrangements with a dental provider in a project's service area. The dental clinic must be willing to accept out-of-area clients who need dental services, including emergency services for adults and Early and Periodic Screening, Diagnosis and Treatment (EPSDT)-referral children. Medically Underserved Areas (MUAs) and Health Professional Shortage Areas (HPSAs) shall receive special priority for grants under this program.

(b) Eligible applicants. The following entities are eligible to apply for grants:

(1) Local health departments.

(2) Federally Qualified Health Centers (FQHCs).

(3) Rural health clinics (RHCs).

(c) Use of grant moneys. Grant moneys must be used to support projects that develop dental services to meet the dental health care needs of Department of Healthcare and Family Services Dental Program clients. Grant moneys must be used for operating expenses, including, but not limited to: insurance; dental supplies and equipment; dental support services; and renovation expenses. Grant moneys may not be used to offset existing indebtedness, supplant existing funds, purchase real property, or pay for personnel service salaries for dental employees.

(d) Application process. The Department shall establish procedures for applying for dental clinic grants.

(Source: P.A. 96-67, eff. 7-23-09; 96-1000, eff. 7-2-10; 97-689, eff. 6-14-12.)

(305 ILCS 5/12-4.40)

Sec. 12-4.40. Payment Recapture Audits. The Department of Healthcare and Family Services is authorized to contract with third-party entities to conduct Payment Recapture Audits to detect and recapture payments made in error or as a result of fraud or abuse. Payment Recapture Audits under this Section may be performed in conjunction with similar audits performed under federal authorization.

A Payment Recapture Audit shall include the process of identifying improper payments paid to providers or other entities whereby accounting specialists and fraud examination specialists examine payment records and uncover such problems as duplicate payments, payments for services not rendered, overpayments, payments for unauthorized services, and fictitious vendors. This audit may include the use of professional and specialized auditors on a contingency basis, with compensation tied to the identification of misspent funds.

The use of Payment Recapture Audits does not preclude the Office of the Inspector General or any other authorized agency employee from performing activities to identify and prevent improper payments.

(Source: P.A. 96-942, eff. 6-25-10; 97-333, eff. 8-12-11.)

(305 ILCS 5/12-4.41)

Sec. 12-4.41. Public Benefits Fraud Protection Task Force.

(a) Purpose. The purpose of the Public Benefits Fraud Protection Task Force is to conduct a thorough review of the nature of public assistance fraud in the State of Illinois; to ascertain the feasibility of implementing a mechanism to determine the pervasiveness and frequency of public assistance fraud; to calculate the detriment of public assistance fraud to the financial status and socio-economic status of public aid recipients specifically and Illinois taxpayers generally; and to determine if more stringent penalties or compassionate procedures are necessary.

(b) Definitions. As used in this Section:

"Task Force" means the Public Benefits Fraud Protection Task Force.

"Public assistance" or "public aid" includes, without limitation, Medicaid, TANF, the Illinois LINK Program, General Assistance, Transitional Assistance, the Supplemental Nutrition Assistance Program, and the Child Care Assistance Program.

(c) The Public Benefits Fraud Protection Task Force. The Public Benefits Fraud Protection Task Force is created. The Task Force shall be composed of 17 members appointed as follows:

(1) One member of the Illinois Senate appointed by the President of the Senate, who shall be co-chair to the Task Force;

(2) One member of the Illinois Senate appointed by the Senate Minority Leader;

(3) One member of the Illinois House of Representatives appointed by the Speaker of the House of Representatives, who shall be co-chair to the Task Force;

(4) One member of the Illinois House of Representatives appointed by the House Minority Leader;

(5) The following persons, or their designees: the Director of Public Health, the Director of Healthcare and Family Services, and the Secretary of Human Services;

(6) The Director of the Illinois Department on Aging, or his or her designee;

(7) The Executive Inspector General appointed by the Governor, or his or her designee;

(8) The Inspector General of the Illinois Department of Human Services, or his or her designee;

(9) A representative from the Office of the Attorney General Medicaid Fraud Control Unit;

(10) Three persons, who are not currently employed by a State agency, appointed by the Secretary of Human Services, one of whom shall be a person with professional experience in child care issues, one of whom shall be a person with knowledge and experience in legal aid services, and one of whom shall be a person with knowledge and experience in poverty law;

(11) The Attorney General, or his or her designee;

(12) A representative of a union representing front line State employees who administer public benefits programs; and

(13) A representative of a statewide business association.

(d) Compensation and qualifications. Members shall serve without compensation and shall be adults and residents of Illinois.

(e) Appointments. Appointments shall be made 90 days from the effective date of this amendatory Act of the 96th General Assembly.

(f) Hearings. The Task Force shall solicit comments from stakeholders and hold public hearings before filing any report required by this Section. At the public hearings, the Task Force shall allow interested persons to present their views and comments. The Task Force shall submit all reports required by this Section to the Governor and the General Assembly. In addition to the reports required by this Section, the Task Force may provide, at its discretion, interim reports and recommendations. The Department of Human Services shall provide administrative support to the Task Force.

(g) Task Force duties. The Task Force shall gather information and make recommendations relating to at least the following topics in relation to public assistance fraud:

(1) Reviews of provider billing of public aid claims.

(2) Reviews of recipient utilization of public aid.

(3) Protocols for investigating recipient public aid fraud.

(4) Protocols for investigating provider public aid fraud.

(5) Reporting of alleged fraud by private citizens through qui tam actions.

(6) Examination of current fraud prevention measures which may hinder legitimate aid claims.

(7) Coordination between relevant agencies in fraud investigation.

(8) Financial audit of the current costs borne by aid recipients and Illinois government through fraud.

(9) Examination of enhanced penalties for fraudulent recipients and providers.

(10) Enhanced whistleblower protections.

(11) Voluntary assistance from businesses and community groups in efforts to curb fraud.

(h) Task Force recommendations. Any of the findings, recommendations, public postings, and other relevant information regarding the Task Force shall be made available on the Department of Human Services' website.

(i) Reporting requirements. The Task Force shall submit findings and recommendations to the Governor and the General Assembly by December 31, 2011, including any necessary implementing legislation, and recommendations for changes to policies, rules, or procedures that are not incorporated in the implementing legislation.

(j) Dissolution of Task Force. The Task Force shall be dissolved 90 days after its report has been submitted to the Governor's Office and the General Assembly.

(Source: P.A. 103-145, eff. 10-1-23.)

(305 ILCS 5/12-4.42)

Sec. 12-4.42. Medicaid Revenue Maximization.

(a) Purpose. The General Assembly finds that there is a need to make changes to the administration of services provided by State and local governments in order to maximize federal financial participation.

(b) Definitions. As used in this Section:

"Community Medicaid mental health services" means all mental health services outlined in Part 132 of Title 59 of the Illinois Administrative Code that are funded through DHS, eligible for federal financial participation, and provided by a community-based provider.

"Community-based provider" means an entity enrolled as a provider pursuant to Sections 140.11 and 140.12 of Title 89 of the Illinois Administrative Code and certified to provide community Medicaid mental health services in accordance with Part 132 of Title 59 of the Illinois Administrative Code.

"DCFS" means the Department of Children and Family Services.

"Department" means the Illinois Department of Healthcare and Family Services.

"Care facility for persons with a developmental disability" means an intermediate care facility for persons with an intellectual disability within the meaning of Title XIX of the Social Security Act, whether public or private and whether organized for profit or not-for-profit, but shall not include any facility operated by the State.

"Care provider for persons with a developmental disability" means a person conducting, operating, or maintaining a care facility for persons with a developmental disability. For purposes of this definition, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court.

"DHS" means the Illinois Department of Human Services.

"Hospital" means an institution, place, building, or agency located in this State that is licensed as a general acute hospital by the Illinois Department of Public Health under the Hospital Licensing Act, whether public or private and whether organized for profit or not-for-profit.

"Long term care facility" means (i) a skilled nursing or intermediate long term care facility, whether public or private and whether organized for profit or not-for-profit, that is subject to licensure by the Illinois Department of Public Health under the Nursing Home Care Act, including a county nursing home directed and maintained under Section 5-1005 of the Counties Code, and (ii) a part of a hospital in which skilled or intermediate long term care services within the meaning of Title XVIII or XIX of the Social Security Act are provided; except that the term "long term care facility" does not include a facility operated solely as an intermediate care facility for the intellectually disabled within the meaning of Title XIX of the Social Security Act.

"Long term care provider" means (i) a person licensed by the Department of Public Health to operate and maintain a skilled nursing or intermediate long term care facility or (ii) a hospital provider that provides skilled or intermediate long term care services within the meaning of Title XVIII or XIX of the Social Security Act. For purposes of this definition, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court.

"State-operated facility for persons with a developmental disability" means an intermediate care facility for persons with an intellectual disability within the meaning of Title XIX of the Social Security Act operated by the State.

(c) Administration and deposit of Revenues. The Department shall coordinate the implementation of changes required by Public Act 96-1405 amongst the various State and local government bodies that administer programs referred to in this Section.

Revenues generated by program changes mandated by any provision in this Section, less reasonable administrative costs associated with the implementation of these program changes, which would otherwise be deposited into the General Revenue Fund shall be deposited into the Healthcare Provider Relief Fund.

The Department shall issue a report to the General Assembly detailing the implementation progress of Public Act 96-1405 as a part of the Department's Medical Programs annual report for fiscal years 2010 and 2011.

(d) Acceleration of payment vouchers. To the extent practicable and permissible under federal law, the Department shall create all vouchers for long term care facilities and facilities for persons with a developmental disability for dates of service in the month in which the enhanced federal medical assistance percentage (FMAP) originally set forth in the American Recovery and Reinvestment Act (ARRA) expires and for dates of service in the month prior to that month and shall, no later than the 15th of the month in which the enhanced FMAP expires, submit these vouchers to the Comptroller for payment.

The Department of Human Services shall create the necessary documentation for State-operated facilities for persons with a developmental disability so that the necessary data for all dates of service before the expiration of the enhanced FMAP originally set forth in the ARRA can be adjudicated by the Department no later than the 15th of the month in which the enhanced FMAP expires.

(e) Billing of DHS community Medicaid mental health services. No later than July 1, 2011, community Medicaid mental health services provided by a community-based provider must be billed directly to the Department.

(f) DCFS Medicaid services. The Department shall work with DCFS to identify existing programs, pending qualifying services, that can be converted in an economically feasible manner to Medicaid in order to secure federal financial revenue.

(g) (Blank).

(h) Public health departments. The Department shall identify unreimbursed costs for persons covered by Medicaid who are served by the Chicago Department of Public Health.

The Department shall assist the Chicago Department of Public Health in determining total unreimbursed costs associated with the provision of healthcare services to Medicaid enrollees.

The Department shall determine and draw the maximum allowable federal matching dollars associated with the cost of Chicago Department of Public Health services provided to Medicaid enrollees.

(i) Acceleration of hospital-based payments. The Department shall, by the 10th day of the month in which the enhanced FMAP originally set forth in the ARRA expires, create vouchers for all State fiscal year 2011 hospital payments exempt from the prompt payment requirements of the ARRA. The Department shall submit these vouchers to the Comptroller for payment.

(Source: P.A. 100-201, eff. 8-18-17; 101-209, eff. 8-5-19.)

(305 ILCS 5/12-4.44)

Sec. 12-4.44. Report on centralizing administrative functions. The Department of Healthcare and Family Services, with the cooperation of the Department of Human Services, shall provide a report to the General Assembly by January 1, 2012, regarding the feasibility and potential consequences of centralizing administrative functions, to the extent allowable under federal law, for applicants applying only for medical assistance. The report shall include, but need not be limited to, an analysis of centralizing administrative functions in a statewide or regional centers administered by either public or private entities, and an analysis of the impact of removing medical assistance only cases from the caseload assigned to employees in local Department of Human Services field offices that accept and process applications for benefits.

(Source: P.A. 97-172, eff. 7-22-11.)

(305 ILCS 5/12-4.45)

Sec. 12-4.45. Third party liability.

(a) To the extent authorized under federal law, the Department of Healthcare and Family Services shall identify individuals receiving services under medical assistance programs funded or partially funded by the State who may be or may have been covered by a third party health insurer, the period of coverage for such individuals, and the nature of coverage. A company, as defined in Section 5.5 of the Illinois Insurance Code and Section 2 of the Comprehensive Health Insurance Plan Act, must provide the Department eligibility information in a federally recommended or mutually agreed-upon format that includes at a minimum:

(1) The names, addresses, dates, and sex of primary covered persons.

(2) The policy group numbers of the covered persons.

(3) The names, dates of birth, and sex of covered dependents, and the relationship of dependents to the primary covered person.

(4) The effective dates of coverage for each covered person.

(5) The generally defined covered services information, such as drugs, medical, or any other similar description of services covered.

(b) The Department may impose an administrative penalty on a company that does not comply with the request for information made under Section 5.5 of the Illinois Insurance Code and paragraph (3) of subsection (a) of Section 20 of the Covering ALL KIDS Health Insurance Act. The amount of the penalty shall not exceed $10,000 per day for each day of noncompliance that occurs after the 180th day after the date of the request. The first day of the 180-day period commences on the business day following the date of the correspondence requesting the information sent by the Department to the company. The amount shall be based on:

(1) The seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation.

(2) The economic harm caused by the violation.

(3) The history of previous violations.

(4) The amount necessary to deter a future violation.

(5) Efforts to correct the violation.

(6) Any other matter that justice may require.

(c) The enforcement of the penalty may be stayed during the time the order is under administrative review if the company files an appeal.

(d) The Attorney General may bring suit on behalf of the Department to collect the penalty.

(e) Recoveries made by the Department in connection with the imposition of an administrative penalty as provided under this Section shall be deposited into the Public Aid Recoveries Trust Fund created under Section 12-9.

(Source: P.A. 98-130, eff. 8-2-13; 98-756, eff. 7-16-14.)